Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps.

BACKGROUND: The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. METHODS: To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. RESULTS: Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. CONCLUSION: This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.

Postburn Reconstruction of the Face and Neck.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the cardinal principles in the management of postburn deformities in the face and neck. 2. Understand reconstruction of specific subsites in the face and neck affected by burn contracture. 3. Acquire knowledge about the various techniques of burn reconstruction of the face and neck. 4. Grasp technical nuances and select appropriate surgical options for individual cases. SUMMARY: Postburn contractures in the face and neck region are multifactorial in origin and difficult to prevent in extensive burns. Facial burns lead to distortion of anatomical landmarks, causing aesthetic, functional, and psychological problems. Each subunit of the face is unique in structure; thus, the surgeon needs to adjust the timing of surgery and the technique according to region and the severity of contracture. Contracture of one unit, especially that of the neck and forehead, can exaggerate the contracture in neighboring subunits. The role of these extrinsic influences must be considered while sequencing surgical procedures. The burn surgeon must be adept in all reconstructive surgery techniques from skin grafting to tissue expanders to microsurgery to obtain the best outcomes. Surgery must be followed up with long-term physical therapy and psychological rehabilitation to help burn survivors with head and neck contractures to integrate back into society.

Nonvascularized Free Toe Phalangeal Transfers in Congenital Hand Differences: Radiological, Functional, and Patient/Parent-Reported Outcomes.

PURPOSE: To evaluate radiologically, functionally and by patient-reported outcome measures, nonvascularized free toe phalangeal transfer (NVFTT) in the reconstruction of congenital short fingers with redundant soft tissue. METHODS: Nineteen children who underwent NVFTT in 40 digits were studied. Of these, 13 patients with a mean follow-up of 5.2 years were assessed radiologically for epiphyseal patency, growth, growth rate, and length comparison with the contralateral toe. Eight children were available for an in-person follow-up. In these patients, we measured the pinch strength and range of motion. The Pediatric Outcomes Data Collection Instrument; the upper extremity, depression, anxiety, pain interference, and peer relationships domains of the Patient-Reported Outcomes Measurement Information Systems; and the aesthetic component of the Michigan Hand Questionnaire were used for the assessment of psychosocial impact. RESULTS: An open epiphysis was found in 24 of 31 grafts. Among these, 20 of 21 grafts were in 9 children younger than 18 months and 4 of 10 grafts were in children older than 18 months at the time of operation. The mean growth was 3.4 mm. The mean growth rate was 1.3 mm/y. Length was 71.8% of the contralateral phalanx. The key pinch strength was 1.3 kg (2.6 kg on the normal side). The mean range of motion at the metacarpophalangeal joint was -4° to 65° flexion. Two proximal interphalangeal joints were stiff and 2 had range of motion of 0° to 30°. Children evaluated with Pediatric Outcomes Data Collection Instrument had high mean scores in all domains. The Patient-Reported Outcomes Measurement Information Systems scores were low for the upper-extremity domain. On the aesthetic component of the Michigan Hand Questionnaire, children gave higher scores than parents. Donor toes, though short, did not cause a functional disability. CONCLUSIONS: NVFTT reliably provides length, stability, and movement in short fingers with redundant soft tissue. In addition to good radiological and clinical outcomes, the patient-reported outcome measures support performing NVFTT in children. Surgery before 18 months, extraperiosteal harvests of grafts, and avoidance of tight skin closures are important. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Perception of Breast Reconstruction among 10,299 Indian Women.

BACKGROUND: Less than 1% of women undergo breast reconstruction after mastectomy in India. To understand if the perception of breast reconstruction among Indian women is a contributing factor, a survey of 10,299 women was done. METHOD IN TOTAL: 10,299 women answered questions from a questionnaire with the help of social workers (10,005) and using the Surveymonkey App (294). RESULTS AN ESTIMATED: 48.8% of women were aware of breast reconstruction. Around 77.5% felt that women would feel depressed after mastectomy, and 76.5% said they would prefer breast reconstruction. Irrespective of age and financial status, most women preferred breast reconstruction after mastectomy. Autologous reconstruction (79.6%) was preferred to implant reconstruction (20.4%). An estimated 71.3% liked the idea of a DIEP flap. When explained that DIEP flap may take 6-8 hours of surgery and cost about US $3500, only 48.8% would go for a DIEP flap. For early breast cancers, women preferred breast conservation surgery (65.7%) to mastectomy and breast reconstruction (34.3%). Women felt that the best way to increase awareness of breast reconstruction would be by social media (47.8%) followed by word of mouth (16.4%), television (13.4%), newspapers (11.7%), and magazines (10.6%). CONCLUSIONS: Although the breast reconstruction rates are very low, women preferred breast reconstruction to mastectomy alone regardless of age and financial status. The surgical teams should devise strategies to assure woman that they can achieve reliable reconstruction at an affordable cost. Increasing experience and reduction of operation time would make autologous breast reconstruction affordable. This strategy could apply to most developing economies.

Trunkoplasty after massive weight loss - a case series with a one-stage body contouring procedure for the NHS patient.

Body contouring post massive weight loss (MWL) is a considerable task and is often a functional rather than esthetic operation. Clinicians are often encouraged to solve multiple issues in a single setting that can be difficult in the MWL patient. A simple abdominoplasty often does not provide a satisfactory outcome in such patients and may result in disharmony of the esthetic unit of the trunk. Trunkoplasty is a technique that combines a fleur-de-lis abdominoplasty and reverse abdominoplasty. This is a one-stage operation to address the extra skin of the whole trunk esthetic unit. The average operation time was 4 h with a 3-surgeon team. No blood transfusions were required. There were 3 out of 15 patients with wound-related problems and no incidence of postoperative hematomas. There were no returns to theaters. Seromas formed were not symptomatic and no interventions were required. The average inpatient stay was 6.9 days and a return to work after 4 weeks. It can improve abdominal contour, define the waist, and improve mons ptosis in one stage without any change in position. This procedure has some specific advantages (accommodates preexisting abdominal scars), but also has shortcomings as compared to "standard" circumferential body contouring.

Rhinoplasty Refinements: Addressing the Deviated, Overprojected Nose.

Deprojection of an overprojected nose and correction of an infralobular deformity are very challenging for rhinoplasty surgeons because a systematic approach is needed to correct these problems. A deviated nose with a dorsal hump is a common deformity that is best treated using septal reconstruction and the component dorsal hump reduction technique using an open rhinoplasty approach. This article and its videos show how to correct a deviated nose with overprojection and a dorsal hump deformity.

Rhinoplasty Refinements: Revision Rhinoplasty Using Fresh Frozen Costal Cartilage Allograft.

A crooked nose is challenging for a surgeon and needs to be treated using a systematic approach. Correction of nasal deformities such as a retracted columella in a revision rhinoplasty may need additional cartilage to correct the framework. Fresh frozen cartilage graft has been used as an extended spreader graft and a columellar strut graft to correct this problem. This option prevents donor-site morbidity associated with harvesting autologous cartilage.

Rhinoplasty Refinements: Addressing the Pollybeak Deformity.

Pollybeak deformity represents one of the most common complications of rhinoplasty that require revision rhinoplasty for correction. This article helps to understand the basis behind the deformity, which helps us to prevent and to treat this deformity. This article and video also reiterate that systematic facial analysis is important to look for imperfections and asymmetries in other parts of the face and show how a chin augmentation is performed to correct microgenia.

Venous Congestion in Pedicled Frontal Branch Superficial Temporal Artery Flaps Reconstructions for Head and Neck Defects: A Review.

The superficial temporal artery (STA) flap is a versatile flap for head and neck defect reconstruction. It can be based on the frontal branch of the STA and an islanded 360-degree rotation arc for various defects on the scalp, cheek, and auricular region. It provides a nonmicrosurgical option for reconstructing such defects, which is itself relatively easy to perform. However, venous congestion is a problem than often can cause worry to the clinician and hence preclude its use. In this review, we revisit this flap in head and neck reconstruction, with case examples used for reconstruction of defects on the scalp, maxilla, lip, ear, and retroauricular area. The STA flap in our review can be used either as a fasciocutaneous flap or with its fascia alone. The main issue with the STA flap is that it is generally a high-inflow flap with variable outflow. Venous congestion is frequently encountered in our practice, and adequate management of the venous drainage in the postoperative period is crucial in ensuring its success as a versatile and viable option for head and neck reconstruction.

Serial abdominal closure with Gore-tex mesh and Rives-Stoppa for an open abdomen secondary to intra-abdominal hypertension in burns.

Intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) commonly occurs in major burns. To relieve the excess pressure, decompressive laparotomy is done which can lead to an open abdomen. Closure of the abdomen after a decompressive laparotomy is very difficult with bowel oedema. We describe our technique of closing the open abdomen in such situations with a combination of serial abdominal wall closure with a layered mesh and the Rives-Stoppa component separation technique.

Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting.

BACKGROUND: At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability . METHODS: Forty-six patients were evaluated 6 months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen-Taylor test (JTT), and patient-reported outcomes (PROs)-Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson's correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes. RESULTS: MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson's coefficients all ≥0.33, p ≤ 0.05). In this cohort, mean MHQ score was 79 ± 15 and mean DASH score was 13 ± 15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their job after injury. CONCLUSIONS: Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes. PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing and may be used to assess post-traumatic disability.

Epidemiology of burns in a teaching hospital in south India.

Despite many medical advances, burns continue to remain a challenging problem due to the lack of infrastructure and trained professionals as well as the increased cost of treatment, all of which have an impact on the outcome. There is very little information on the pattern of outcomes among burn patients in relation to clinical aspects in India. Hence, the present study was undertaken in a burns unit to determine selected epidemiological variables, assess the clinical aspects (etiology, extent and anatomical location) and first aid measures adopted and finally to analyse the outcomes in cases of burn injuries. In addition, we have sought to suggest measures to remove myths about pre-hospital burn treatment and provide recommendations to healthcare professionals.